Smooth Transitions: Enhancing the Safety
of Planned Out-of-Hospital Birth
Transports - A QI Initiative of the
Washington State Perinatal Collaborative
Physician-Licensed Midwife Work Group
A Task Force of the
Statewide Perinatal Advisory Committee
State of Washington
Department of Health
Grand Rounds
Department of Obstetrics and Gynecology
School of Medicine
University of Washington
Wednesday 01/30/2013
Presentation by
• Robert H. Palmer jr, MD, FACOG
• Co-Chair, Physician-Licensed Midwife
Work Group
• OB Hospitalist, Obstetrix Medical Group
• Swedish Medical Center, Seattle &
Issaquah
• bobpalmermd@gmail.com
• 360.531.2525 cell
Disclosures
• The speaker has no conflicts of interest to
disclose.
Learning Objectives
• Understand the categories of midwives in WA
state
• Understand the training and experience prior to
licensure of Licensed Midwives
• Understand the scope of out-of-hospital births in
WA state
• Understand the scope of practice of LM’s
• Understand the liability issues involving LM’s
• Understand how to begin to streamline the
process of planned out-of-hospital birth
transports
Three Categories of Midwives
Recognized in Washington State
• Lay Midwives
• Licensed Midwives (LM)
• LM’s may also hold a national credential of
Certified Professional Midwife (CPM)
• Certified Nurse Midwives (CNM), in New
York State, Certified Midwives (CM)
Lay Midwives
• Recognized under WA law since 1917
• Generally, any person, usually a woman,
usually age 18 or over, may attend a
woman giving birth or assist with labor and
delivery
• May not advertise, have business cards,
letterhead, or take any payment in cash,
trade, or goods-in-kind for the midwifery
services rendered
Licensed Midwives
• WA first licensed midwives in 1980
• 2012: 109 LM in WA
• 2010: delivered approx. 2,295 babies (2.7% WA
births are with LM’s. Up from 1.9% in 2006)
• 12%-25% (275-574) of women who begin
the process of a planned out-of-hospital birth
require transport to an acute-care hospital either
during labor, or during the postpartum period
Hospital Transfers
• Intrapartum transfer rates range from 12-20%
• 75-80% of transfers are primiparas
• 51% are for prolonged labor, pain relief or
exhaustion
• 96.5% are non-urgent
• 50-66% deliver vaginally
• 1.3% of mothers were transferred immediately
postpartum, primarily for hemorrhage and
retained placenta
• 0.7% of newborns were transferred after birth,
primarily for respiratory problems
2010 WA Births
•
•
•
•
•
Total Births
Hospitals
Birth Centers
Home
Other
86,510
83,972
866
1,616
56
97.1%
1.0%
1.9%
0%
•
•
•
•
MD/DO
CNM
LM
Other
74,944
7,935
2,295
1,336
86.6%
9.2%
2.7%
1.5%
Out-of-Hospital Births in WA
• In 2010, 2.9% of WA’s births occurred in
an out-of-hospital setting (N=2,538)
• 64% at home (N=1,616)
• 34% in licensed freestanding birth centers
(N=866)
• 2% in other locations (N=56)
• 90% of out-of-hospital births in WA are
attended by LM’s
Seattle Midwifery School
• Founded in 1978 by a group of lay midwives
• Three-year program for direct-entry midwives
• Accredited
– State of Washington, Department of Health
– Midwifery Education Accreditation Council
• Formerly the leading educator of LM’s in WA
• Merged with Bastyr University in March 2010
and now a Master’s-level program
LM Educational Tracks
• Complete a 3-year education from a WA state-approved
school, including attending a minimum of 100 births, or
• Graduate from an equivalent program from another state
or country, or
• Present documentation of completion of “equivalent
subject matter...and a number of clinical managements
under a (qualified) preceptor,” and
• Pass an examination provided to the state by the North
American Registry of Midwives (NARM), www.narm.org
Licensed Midwives
• 77 acute-care hospitals in WA who are licensed
to provide obstetrical services
• Currently, there are two licensed midwives with
privileges to deliver babies in WA (Morton &
Coupeville)
• LM’s plan their births in the woman’s home, or in
a licensed freestanding birthing center
• 6 licensed freestanding birth centers in the
greater Seattle area where the births are
attended by LM’s
• 13 licensed freestanding birth centers in WA
state
Licensed Midwives May
•
•
•
•
•
•
•
•
•
Start IV fluids
Maintain saline or heparin locks
Administer:
Prophylactic ophthalmic medication
Postpartum oxytocin
Vitamin K
Rh-immune globulin
Local anesthesia for laceration repair
Magnesium sulfate for prevention of maternal
seizures pending transport
Licensed Midwives May Administer
• Epinephrine for use in maternal anaphylaxis pending transport
• Terbutaline for non-reassuring fetal heart tones and/or cord
prolapse pending transport
• Antibiotics for intrapartum prophylaxis of Group B
streptococcus
• Anti-hemorrhagic drugs to control postpartum hemorrhage,
such as misoprostol per rectum, methylergonovine maleate
(oral or IM), prostaglandin15-methyl F2 alpha (Hemabate)
• MMR vaccine to non-immune mothers postpartum
• HBIG and HBV for neonates born to hepatitis B-positive
mothers
Licensed Midwives
• Licensed by the State of Washington
Department of Health
• Regulated by the State of Washington
Department of Health, Midwife Advisory
Committee
• Disciplined by the State of Washington
Department of Health, Health Services
Quality Assurance Program
Licensed Midwives
• Professional liability insurance is available
in WA state to LM’s through the Joint
Underwriting Association administered by
Washington Casualty Company, Redmond,
WA, www.juawashington.com
• LM’s are reimbursed for obstetrical services
by the state Medicaid program (Department
of Social and Health Services, DSHS) and
most private insurers
Professional Association
• Midwives Association of WA State
(MAWS)
• Voluntary, 82 of 109 (75%) LM’s are
members
• www.washingtonmidwives.org
• MAWS establishes standards of practice ,
provides continuing education, advocacy,
and legislative support
Quality Management Program
• MAWS maintains a QMP with state-protected,
confidential peer-review and incident review; all
professional MAWS members are required to
participate in the QMP
• LM’s are required to self-report sentinel events
within 14 days
• Anyone may submit a report (patient, family
members or other healthcare providers)
• Review includes recommendations and may
include a report to the Department of Health,
pursuant to state law
Liability Insurance
• LM’s may choose to obtain liability insurance
through a state-mandated program, the Joint
Underwriting Association (JUA), Redmond, WA
• www.washingtonjua.com
• 68 or the 109 (62%) LM’s in WA are insured by
the JUA
• Some of the 41 LM’s not insured through the
JUA may have purchased other coverage
• All 13 licensed freestanding birth centers in WA
have liability coverage through the JUA
Professional Liability Issues
• Three major professional liability insurers in WA:
Physicians Insurance, Medical Protective, The
Doctors Company, all
• Ask their insureds not to form formal
relationships with LM’s (which might be
interpreted as a “loaning” of the physician’s
liability limits to the LM)
• Cover their insureds when their insureds are on
emergency obstetrical call and are asked to care
for any woman brought to the hospital for
obstetrical care, including those being
transported under a LM’s care
Professional Liability Issues
• In addition, Physicians Insurance allows
their insureds to respond to an outpatient
consultation request from a LM as they
would respond to a consultation request
from any other licensed health-care
professional
LM/OB Roles
• The midwifery client is best served by
discussion in the prenatal course about
possible outcomes, need for transfer
• The midwifery client is best served by
discussion speaking about OB physicians
and hospitals in positive terms
• The midwifery client is best served by
preparing her for what services she will
need in the hospital
LM/OB Roles
• The midwifery client is best served when
transferred in a timely manner, with
complete prenatal records that are selfexplanatory
• The hospital staff serves the patient best
by quickly and smoothly receiving the
patient, getting her admitted to the labor
and delivery unit, and notifying the on-call
OB physician of the admission
LM/OB Roles
• The OB MD serves the patient best by
providing competent, kind, compassionate,
and timely care
• The OB MD serves the patient best by
being non-judgmental about the patient’s
planned out-of-hospital birth
• The OB MD serves the patient best by
treating the LM with respect
LM/OB Roles
• The OB MD serves the patient best by
returning the patient to the LM with a
discharge summary when the patient is
discharged from the hospital and follow-up
care with the LM is appropriate
• The LM serves the patient best by
relinquishing control of the care of her
client to the hospital staff
LM/OB Roles
• The LM serves the patient best by being
supportive of her client and being
supportive of the hospital staff
• All providers must create a peaceful,
supportive, caring environment within the
hospital setting to provide the care the
mother and her baby came to the hospital
to receive
Smooth Transitions
• Created in September 2005
• Need to improve the process of out-of-hospital
birth transport
• Form a pre-hospital perinatal transport
committee, composed of
• Local licensed midwives
• Obstetricians
• Emergency Department Physician & Nursing
Leadership
• Obstetrical Nurse Manager
• Obstetrical Charge Nurses
• Appropriate Hospital Administrators
Pre-Hospital Perinatal Transport
Committee
• Parties getting acquainted with each other
• Learn each other’s needs when a
transport becomes necessary
• Agree upon communication pathways
• Hospital staff defines needs in terms of
necessary information, how that
information is to be provided and to whom
Pre-Hospital Perinatal Transport
Committee
• LM and OB MD need to understand how
to transfer the patient’s care, and
• How to return the patient to the LM upon
discharge from the hospital
• Communication includes understanding
the prenatal record system of the LM and
for the OB MD (or pediatrician) to provide
a discharge summary to the LM
Pre-Hospital Perinatal Transport
Committee
• This committee is encouraged to develop an
evaluation process that surveys satisfaction from
the patient, the LM, the nursing staff and the
medical staff involved
• This evaluation form should solicit examples of
what went well/smoothly, and what could use
improvement
• Twice a year (at least) this committee should
meet and recognize successes and look for
ways of improving the process
Pre-Hospital Perinatal Transport
Committee
• At year end, the hospital committee is
encouraged to make a report to the Smooth
Transitions Project Coordinator about their
experience with the Smooth Transitions
program, which in turn would share the
report with the Statewide Perinatal Advisory
Committee
• This report (and all survey instruments)
should be free of any patient or provider
identifiers
For More Information
• WA State Perinatal Collaborative:
www.waperinatal.org
• Smooth Transitions Project Coordinator:
Melissa Hughes, LM, 206.697.2226
SmoothTransitionsPC@gmail.com
• Bob Palmer, MD, 360.531.2525
bobpalmermd@gmail.com